The Post Rehab Blog Has Moved!!

You can find the Post Rehab Blog now at www.postrehabblog.com. Please visit us there for information to help you build a profitable post rehab practice and effectively manage a wide range of medical exercise clients. Happy Holidays!!

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The knee meniscus - Where is it and what does it do?

The menisci of the knee are the most important structures in the knee. The cruciates are important to knee stability but the menisci are most important because at this point, the menisci cannot be repaired or regenerated. There are two menisci, the medial and lateral, found in each knee. The larger of the two menisci is the medial. The most often damaged of the two is also the medial meniscus. For more more detailed anatomical review of the knee menisci, please click the link below to our video outlining the knee meniscus.

Dr Mike

ACL Graft - Hamstring or Patella Tendon?

Tiger Woods recently underwent an ACL reconstruction using a hamstring graft. But many professionals athletes have the ACL reconstructed using the patella tendon graft. Why use the hamstring tendon opposed to the patella tendon?

We know the patella tendon draft is 110% (research estimates) stronger than the original ACL but some surgeons still prefer the hamstring graft. This is because the hamstring is vascularized immediately and the hamstring does not cause as many issues with the development of scar tissue. The patella tendon is the stronger of the two grafts but the patella tendon is stronger but it must re-vascularize after the surgery. Re-vsacularization is vitally important to the stability and resiliency of the new ligament. The patella tendon graft does have a slightly higher incidence of scarring but the durability of the graft makes it very attractive for use with athletes.

The selection of the graft may be affected by the age of the client, the degree of knee instability and the preference of the surgeon. The outcome studies on the use of the two grafts doesn't show a significant advantage for either. Physician preference and comfort are usually the deciding factor in graft selection.

For you the PRP, the most important knowledge our need regarding the graft selection is the intensity level of progression the graft can tolerate. Usually the patella tendon graft and tolerate greater forces at the 4-6 month mark than the hamstring graft. But overall, the functional outcomes for both grafts are the same. With both grafts caution with the last 30 degrees of open-chain knee extension is important.

Dr Mike

The ACL - Where is it and what does it do?

The recent ACL rupture in Tom Brady's knee and the reconstructive surgery that Tiger Woods recently underwent has highlighted the ligaments of the knee. There are 4 primary ligaments of the knee. These include the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL). The cruciates are major stabilizers in the knee. The ACL is important in maintaining stability in the knee during dynamic activities such as cutting, turning, pivoting and changing direction. The ACL prevents the anterior translation of the tibia beneath the femur. The tear of the ACL allows the uncontrolled movement of the femur on top of the tibia. That uncontrolled movement may cause menisical damage. Meniscal damage may lead to arthritic changes in the knee. Click the link below to watch the review of the major ligament structures in the knee.

Dr Mike

Post Rehab Programming to Increase Revenue

The summer is over and schools are opening. Thoughts now shift to education and getting back into the groove of work, study and exercise. This fall is a great time to offer group based post rehab programming such as the Dynamic Back School or Women's Fitness 101. These two programs are easily introduced in a club or private studio setting and they will allow you to capture a new group of clients. The group based approach to the client with medical issues will allow you to tap into the medical market at a lower price point but with an opportunity for significant revenue. We recommend a $180-225 fee per participant in the back school or Women's Fitness 101. These programs are delivered in six sessions over a 30-day period. The thirty day approach is very attractive to medical professional who are usually very reluctant to refer patients to long-term fitness programs. In my next blog post I will explain the Dynamic Back School.

Dr Mike

Do you know the symptoms of mild knee arthritis and how those symptoms translate to x-ray studies?

As many of you know I am an avid golfer and a former army paratrooper. Between the acl rupture and meniscal damage sustained during my army career and the wear and tear on the right knee from my quest to over take Tiger's number 1 ranking, (I dont think Tiger has much to worry about), I have a low level effusion (swelling) of the knee. I have no pain but occasionally a feeling of stiffness after playing more than 18 holes. My knee's tolerance level seems to be about 18 holes of golf before effusion begins. Steep inclines, hitting out of sand traps and just the 18 holes of compression on the knee seem to be the major issues. I have no feeling of giving way or instability.

Here's your post rehab challenge. Develop an exercise program for a 46 year old male he can perform at home. You have a Bowflex, a stationary bike, dumbbells from 10-50 pounds and a Swiss ball. The program goal is at the end of 18 holes there is minimal effusion with no residual stiffness the next morning. Take a look at the x-rays below for a look at arthritic changes that causes a mild effusion in the knee. The knee on the right shows narrowing along the lateral joint line and if you look closely you will see mild osteophytes (bone spurs) right at the joint line. This x-ray shows the early stages of osteoarthritis of the knee.




Dr Mike

Post Rehab Referrals - How do I contact physical therapists, physicians and chiropractors?

The lifeblood of any post rehab or medical exercise practice is developing referral relationships with local medical professionals. Approaching physical therapists, chiropractors and/or physicians requires an organized process as well as understanding the needs of these referral sources. You must develop a post rehab/medical exercise marketing package and presentation to maximize your chances of establishing a referral relationship. Once you make your presentation but referrals aren't coming in you must ask yourself four questions. The organized approach, the contents of the post rehab marketing package and the four questions are included in my recent interview with David Gilks, MEPD. Please click the link below to listen and learn how to contact medical professionals.


Dr Mike

I referred my client to a physician but he never came back. How do I get my client back?

In an earlier blog post I discussed a problem many post rehab professionals encounter, the loss of a client when you refer the client to a medical professional for an evaluation. Here are three strategies you can use to prevent the loss of your client.

1) Send a letter of introduction to the medical professional. This letter should be given to the medical professional by the client and not given to the front desk staff or nurse. This letter will introduce your client and outline the exercise program you developed for the client as well as listing the client's complaints. In the letter request the evaluator to contact you with recommendations for modification of the client's exercise program.

2) Contact the medical professional's office the next day to find out if exercise modifications are warranted and/or if the client needs medical treatment. Also, thank the medical professional for assessing the client.

3) Contact the client and ask the outcome of the evaluation visit and the recommendations given to the client.

One of these three actions will allow you to obtain the information you need to modify the client's exercise program and avoid the loss of your client. Sometimes medical professionals may dismiss you because they simply don't understand you want to be involved in the management of the client's condition. This is where clearly outlining your role/scope as well as the benefits exercise offers to the client (without exercising the affected area) can win the day and develop a referral relationship with the medical professional. I can't say this will happen in 100% of the cases but it will help establish you as the post rehab professional in your community.

Dr Mike

When I make a referral to a medical professional my client never comes back, what do I do?

I am a strong advocate for referring clients in your post rehab practice to a medical professional for evaluation if you encounter a situation beyond your scope of practice. But more post rehab professionals are noting the complete loss of the client referred. The medical professional may advise the client simply to discontinue exercise or institute a program of treatment for the client without communicating the findings of the assessment and/or recommenndations for treatment. I can see how this can be very frustrating for the post rehab professional. In your attempt to act professionally by making a referral to lose the client annd receive no communication. I would certainly feel used.

I would follow up with the client directly and find out what recommendations were made. If you have made a referral and sent along a letter of introduction with your client, you certainly deserve to know the outcome of the visit. In this situation, I will admit this is not professional conduct on the part of the medical professional. Medical professionals regularly receive referrals and common practice is to send a follow-up report to the referral source with recommendations and a thank you. I can only guess the medical professional may not feel a referral from a fitness professional warrants a follow-up report. In one of my next blog posts I will note a strategy that will help you eliminate this situation and make it easier to communicate with medical professionals.

If you have encountered this issue, please share your experience with other post rehab professionals by commenting here on the Post Rehab Blog. Thanks.

Dr Mike

3 Keys to Managing the Post Rehab LCL Sprain

We spoke about managing the MCL post rehab client and now we will discuss managing the LCL post rehab client. Some of the keys are same for the MCL but there is one important distinction. The 3 keys are:

1) Limit knee flexion to less than 90 degrees.

2) Strengthen the quadriceps and hamstrings.

3) Avoid activities that increase swelling and/or pain.

These 3 keys are very similar for the post rehab management of the MCL client. Listen to my discussion of these 3 keys by clicking the link below.

Dr Mike

3 Keys to Managing the Post Rehab Achilles Tendon Rupture Client

Though we often see Achilles tendon ruptures in the middle-aged population, it is seen in athletes. Once the tendon has healed from the surgical repair or via conservative treatment, this client will need a post rehab program after discharge from physical therapy. The 3 keys to managing the Achilles rupture in a post rehab setting include:

1) Improve and maintain ROM

2) Increase strength and power in the gastroc and soleus

3) Improve stability for return to functional activities

Follow these 3 keys to establish a safe and effective post rehab program for the Achilles tendon rupture. Click the link below to listen to my description of these 3 keys.

Dr Mike

Post Rehabilitation - The Future is Bright and Profitable

AAHFRP offered the first post rehab course, the Medical Exercise Specialist workshop, in Washington, DC in 1994. The acceptance and usage of post rehab services by fitness participants, health clubs, medical professionals and insurance carriers has exceeded our wildest dreams. Our hope was to expose fitness professionals to the basic concepts in exercise management of common medical conditions. Now post rehab fitness has become a standard part of the rehab management model and we see more physical therapy clinics and hospital-based fitness facilities adding post rehab and medical exercise programs throughout North America.

The future of post rehab fitness and medical exercise services are bright. The aging of the baby boomers and the overwhelming numbers of hypertensives, diabetics and other chronic diseases will heighten the need for post rehab fitness and medical exercise services. Within the next decade we will see university exercise physiology and kinesiology programs offering concentrations in medical exercise and post rehab fitness. We will also see physical therapy clinics, sports medicine centers and hospital-based fitness centers establishing the "medical exercise specialist" or "post rehab conditioning specialist" as job titles within the organization with various levels of specialization and training. Insurance carriers will embrace medical exercise as a standard component of treatment for conditions such as diabetes, hypertension and other cardiovascular disorders. The same will be true of post rehab fitness for conditions such as osteoarthritis and disc herniations along with some surgical procedures including acl reconstructions, laminectomies and total joint replacements. Post rehab services will be utilized after physical therapy and chiropractic services once the client is medically stable and has received the maximum benefit from the treatment provided by the licensed medical professionals. Though insurance reimbursement will become common place for post rehab services, group programs will increase as insurance reimbursement decreases per session. Medical exercise specialists and post rehab conditioning specialists will become staff members in physical therapy clinics and sports med centers but licensure is quite a way off. States will begin registering fitness professionals. To obtain insurance reimbursement, post rehab professionals must hold the MES or PRCS certification as well as a personal training certification.

The next decade will one of tremendous growth for the post rehab arena. Opportunities will abound and income will grow but so will administrative tasks such as writing progress reports, documenting sessions and authoring progress summaries. This means a cottage industry will develop around post rehab fitness. Software programs, administrative workshops, liability insurance plans, practice management workshops and even lawsuits will become part of the post rehab phenomenon. Just think of it, higher incomes, greater respect from medical professionals, higher liability premiums and the need to practice defensively. Welcome to the medical community.

3 Keys to Managing the Post Rehab Rotator Cuff Client

Rotator cuff injuries are common in sports requiring overhead activities. The tear of the rotator cuff can be both painful and functionally limiting. The exercise management of rotator cuff tears is based in 3 keys that include:

1) Strengthen the rotator cuff muscles.

2) Avoid overhead activities and increase the subacromial space.

3) Strengthen the periscapular musculature.

These 3 keys form the foundation of a safe and effective post rehab program for the rotator cuff tear client. These keys will optimize the possibilities of a positive functional outcome. Click the link below to listen to the discussion of these 3 keys.

Dr Mike

Post Rehabilitation Red Flags.........when should you refer or proceed with caution?

When should you refer your client to a medical professionals? Do you know the signs your client needs an evaluation by a licensed medical professional? If you are not 100% sure, then using our post rehab red flags might be helpful. These red flags are reviewed in each of our post rehab workshops and these are a vitally important concept all post rehab and corrective exercise professionals must embrace and understand. The red flags are listed above. When you see these red flags, as a post rehab professional, you must refer the client to a medical professional or modify the client's exercise program. It's up to you, the post rehab professional, to determine is a referral or program modification is necessary. For more information on the post rehab red flags go to www.postrehabfoundations.com.

Dr Mike

Corrective Exercise.....when to correct or when to refer?

As post rehab courses and guidelines proliferate, knowing when to appropriately use corrective exercise techniques and post rehab training programs seems to get lost in the discussion. Simply the presentation of a client with a postural fault, muscular imbalance or pain is sometimes not enough of a reason to begin corrective exercise. A thorough medical history and assessment on the client must be completed first. Also, discussion with the client's physician or physical therapist is required to ensure you have the full picture before proceeding with exercise. Its interesting that few corrective exercise or post rehab courses really focus on the pathology and assessment of these postural faults, pain and/or imbalances but they do readily encourage exercise. Remember, posture and pain may be the result of a long-term condition or fault and what we see is not what is really going on with the client. The introduction of corrective exercise can exacerbate a dormant condition. Sometimes pulling the string of a postural fault may cause the breakdown of other faults and result in the client having more pain. Now it is important to get to the underlying problem but if you can't anticipate the possible complications, then you shouldn't begin corrective exercise without a thorough history, assessment and discussion with the client's physician. Remember, what is you see is not what you get in posture or with pain. Though a thorough assessment, medical history, x-rays, CAT Scans and MRI's are not 100% accurate, these allow us to eliminate possible conditions. Then we can start to correct faults with a better understanding of possible causes. I am not saying corrective exercise is not great for clear cut postural faults which are easily corrected. But in the back of your mind you should always think, what other complications might be causing the pain or fault and have I given enough consideration to these complications. What you see with human posture and pain is seldom what you get. If you see red flags, talk to the client's physician or therapist. We will discuss the post rehab red flags in our next blog post.


Dr Mike

3 Keys to Managing the Post Rehab Low Back Pain Exercise Program

Back pain affects 80% of the American population at some point in their lives. For many, this back pain becomes a constant part of their lives. The exercise management of chronic low back pain (LBP) is an important skill the post rehab professional must master. LBP is seen in both the athletic and non-athletic populations. There are 3 key components of the exercise program for the chronic LBP client in a post rehab setting. The 3 key components are:

1) Cardiovascular training with appropriate levels of support.

2) Spinal stabilization including techniques in lifting, pushing, pulling and carrying as well as flexibility training.

3) Lower extremity strengthening.

These 3 components must be included in each LBP client's exercise program design. Include these 3 essential components and you will see positive outcomes with your LBP clients. Click the link below to listen to my discussion of these 3 key components.

Dr Mike

3 Keys to Managing Post Rehab MCL Sprain

Another common injury we see with athletes is the MCL sprain in the knee. The MCL is a stabilizer of the knee and often damaged. Though MCL ruptures are seldom surgically repaired, the occurrence of 1st and 2nd degree sprains is common. The 3 keys to managing this client in a post rehab setting are as follows:

1) Avoid full knee extension until authorized by physician or physical therapist.

2) Strengthen the quad and accentuate vastus medialis recruitment.

3) Avoid activities that increase swelling.

These 3 keys are the foundation of the post rehab program for the MCL client. Also remember, PFS is always lurking with the effused knee. Effuse is common with MCL involvement. Please click the link below to listen to the discussion of these 3 keys.

Dr Mike

Post Rehab Challenge
Your client is a 24 year-old cyclist. She sustained a 2nd degree of the left MCL. She has completed physical therapy and now she has full ROM but an atrohied quadriceps. She has some swelling and point tenderness at the MCL after cycling. How would you adjust the seat for this client and what motion would you limit until the swelling and point tenderness are gone? What complications are associated with knee swelling or effusion?

3 Keys to Managing Post Rehab AC Joint Separations

AC joint sprains are common in contact sports. Sports such as judo have an abundance of AC joint sprains. AC joint sprains and separations are use synonymously. The danger to the AC joint is both cartilaginous and ligamentous. The damage to these structures causes inflammation, pain, instability and weakness in the shoulder. The AC joint separation, on presentation, looks similar to impingement syndrome. The 3 keys to managing AC joint separation are as follows:

1) Limit overhead and full adduction activities

2) Strengthen the rotator cuff

3) Identify AC joint separation

These keys will help you develop a safe and effective post rehab program for the post rehab AC joint separation clinic.

Dr Mike

Post Rehab Challenge
What are the signs and symptoms that identify the AC joint separation? How is the AC joint separation differentiated from shoulder impingement?

3 Keys to Managing the Post Rehab Patello-Femoral Syndrome Client

Patello-Femoral Syndrome (PFS) is another common condition seen in athletes. PFS is associated with weakness of the quadriceps and chronic effusion (swelling). PFS can curtail a post rehab training program. There are 3 keys to managing the post rehab PFS client. The 3 keys are listed below.

1) Recruit the vastus medialis.

2) Stretch the IT band.

3) Strengthen the quadriceps.

4) Control swelling - this is the bonus key.

Click the link below to listen to my discussion of these 3 keys.



Dr Mike

Post Rehab Challenge
Your client is a 46 year-old runner training for a 10K run. She reports low grade anterior knee pain after prolonged sitting. She also has mild swelling after running greater than 2K. Please develop the exercise program for this client and explain how the swelling might assist in the development of PFS.

3 Keys to Managing the Post Rehab Spondylolethesis Client

Spondylolethesis is another condiion commonly seen in athletes. Managing the spondylolethesis is challenging. Spondylolethesis are graded using a 1-4 or 1-3 scale. Severe spondylos (grade 3-4) are sometimes treated surgically. Those spondylos that are non-surgically managed (1-3) should be referred for post rehab conditioning after discharge from physical therapy. There are 3 keys to managing the post rehab spondylolethesis client. The 3 keys are:

1) Determine the grade of the spondylolethesis. This information will come from the physician, physical therapist or chiropractor.

2) Avoid lumbar extension 10 degrees beyond neutral.

3) Strengthen the abdominals and position the client is slight lumbar flexion for normal activities. Slight flexion protects the spinal cord from damage.

Follow these 3 keys to develop a safe and effective post rehab program for the spondylolethesis client. Click the link below to listen to my discussion of these 3 keys.


Dr Mike